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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600488
Report Date: 06/01/2023
Date Signed: 06/01/2023 04:35:24 PM


Document Has Been Signed on 06/01/2023 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:CASA DE LAS CAMPANASFACILITY NUMBER:
374600488
ADMINISTRATOR:KIMBERLY FINCH-DOMINYFACILITY TYPE:
741
ADDRESS:18655 WEST BERNARDO DRIVETELEPHONE:
(858) 451-9152
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:582CENSUS: 459DATE:
06/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Director Kimberly Finch-Dominy and Administrator Brooke HarrisTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to cite a deficiency. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Kimberly Finch-Dominy and Administrator Brooke Harris.

Today's visit was in response to three (3) LIC624 Incident Reports which licensee self-submitted to the CCLD San Diego Regional Office (RO). During today’s visit, LPA briefly toured the facility, collected copies of records, and interviewed staff.

Per the first LIC624: On 03/29/2023, Resident #1 (R1) fell at the facility. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] Licensee sent R1 to the emergency room via 911, where R1 was diagnosed with an “avulsion fracture” on their left elbow. However, Licensee did not send a written report of the incident to CCLD until 05/04/2023.

Per the second LIC624: On 03/30/2023, Licensee sent Resident #2 (R2) to the emergency room for a change in condition involving vomiting, diarrhea, fever, and decreased fluid intake. However, Licensee did not send a written report of the incident to CCLD until 05/04/2023.

Per the third LIC624: On 04/02/2023, Licensee sent Resident #3 (R3) to the emergency room for a change in condition involving severe/pronounced weakness. R3 was subsequently diagnosed with “CHF exacerbation,” pneumonia, and sepsis, requiring antibiotic treatment and twenty-two (22) days of skilled nursing care. However, Licensee did not send a written report of the incident to CCLD until 05/04/2023.


[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: CASA DE LAS CAMPANAS
FACILITY NUMBER: 374600488
VISIT DATE: 06/01/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

A preponderance of evidence exists to show that Licensee did not meet reporting requirements. A deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Finch-Dominy and Harris, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/01/2023 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: CASA DE LAS CAMPANAS
FACILITY NUMBER: 374600488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements: “(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified…below: (D) Any incident which threatens the welfare, safety or health of any resident…”
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As of the date of deficiency issuance, CCLD had already received copies of the written LIC624 Incident Reports for R1, R2, and R3, respectively. This resolves the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, for 3 of 459 residents (R1, R2, and R3), licensee did not submit a written report the licensing agency and the person responsible within seven days of the occurrence of an incident which threatened resident welfare and health, which posed a potential health and personal rights risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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